Best Practices:

Peritoneal Dialysis Programs

Created 2018
Approved by the BCPRA Peritoneal Dialysis Committee
Table of Contents
1.0 Background and purpose........................................................................................1
2.0 Target population and goals of PD program....................................................2
3.0 Requirements for a successful PD program.....................................................2
4.0 PD milestones and patient flow algorithm........................................................3
Figure 1. PD patient flow algorithm......................................................................3
5.0 Transition to PD..........................................................................................................3
5.1 Patient transition: adult and pediatric......................................................3
5.2 PD assessment for PD suitability and referral..................................... 5
Figure 2. Contraindications to PD...................................................................... 5
6.0 PD modality options................................................................................................ 6
6.1 CAPD, APD, IPD............................................................................................. 6
Figure 3. Clinical pathway for CAPD and APD patients...............................7
Figure 4. Assessing for PD prescriptions........................................................ 8
6.2 Acute PD......................................................................................................... 8
6.3 Provincial PD assist program.................................................................... 9
6.4 PD in long-term care facilities..................................................................10
Figure 5. Urgent start clinical pathway............................................................10
6.5 Pediatric PD support services.................................................................. 11
7.0 PD catheter implantation....................................................................................... 11
8.0 Patient goal setting, training/education and treatment planning............. 12
8.1 PD teaching support and tools................................................................ 14
8.2 Training location........................................................................................... 14
8.3 Length of training......................................................................................... 14
8.4 Training content............................................................................................ 15
8.5 Follow-up and retraining............................................................................ 15
8.6 Home visits..................................................................................................... 16
9.0 PD patient follow up............................................................................................... 16
9.1 Clinic appointments..................................................................................... 16
9.2 Laboratory testing........................................................................................ 18
10.0 PD guidelines and protocols..............................................................................20
10.1 ISPD guidelines............................................................................................20
10.2 Provincial standardized PD protocols..................................................20
10.3 PD provincial and program evaluation and recommended
guidelines.......................................................................................................20
10.3.1 Provincial key performance indicators................................... 21
10.3.2 PD program key performance indicators............................ 23
11.0 Advance care planning........................................................................................25
11.1 Pediatric considerations for the appropriate choice of conservative
care or renal replacement therapy.......................................................26
12.0 PD multidisciplinary healthcare team: roles and responsibilities...........28
12.1 Peritoneal dialysis team functions.........................................................29
12.2 Nephrologist.................................................................................................29
12.3 Registered nurse.........................................................................................29
12.4 Registered dietitian.....................................................................................29
BC Provincial Renal Agency • [Link] May 2018
 12.5 Registered social worker..........................................................................29
12.6 Pharmacist.....................................................................................................30
12.7 Licensed practical nurse (LPN)...............................................................30
12.8 Unit co-ordinator (unit clerk)....................................................................30
13.0 Health care clinician training..............................................................................30
13.1 Resources......................................................................................................30
13.2 Conferences.................................................................................................. 31
14.0 Recommended allocation of resources for PD............................................ 32
14.1 BCPRA PD funding model....................................................................... 32
14.2 Application of the BCPRA PD funding model................................... 33
14.3 PD staffing/patient ratios.......................................................................... 33
15.0 PD supply and service delivery......................................................................... 33
15.1 Roles and responsibilities........................................................................ 33
15.1.1 Vendor............................................................................................... 33
15.1.2 PD program..................................................................................... 34
15.1.3 Patient............................................................................................... 35
15.1.4 BCPRA............................................................................................... 35
15.1.5 Purchaser......................................................................................... 35
15.2 Contract.......................................................................................................... 35
15.2.1 Process............................................................................................. 35
15.2.2 Expectations................................................................................... 36
15.2.3 Monitoring....................................................................................... 36
16.0 Appendices
A. Transition to Peritoneal Dialysis............................................................. 37
B. Transitioning to Peritoneal Dialysis-Patient guide............................40
C. Pediatric Transition to Adult Care.......................................................... 41
D. Home therapies: Patient Assessment................................................. 44
E. PD Assist Eligibility Criteria...................................................................... 54
F. . Provincial Guideline: Indications and Urgency Criteria for Surgical PD Catheter Access
Procedure on Adults..................................................................................56
G. BCPRA Funding Model..............................................................................59
17.0 References................................................................................................................ 61

IMPORTANT INFORMATION
!
This BCPRA guideline/resource was developed to support equitable, best practice care for patients with chronic kidney
disease living in BC. The guideline/resource promotes standardized practices and is intended to assist renal programs
in providing care that is reflected in quality patient outcome measurements. Based on the best information available at
the time of publication, this guideline/resource relies on evidence and avoids opinion-based statements where possible;
refer to [Link] for the most recent version.

For information about the use and referencing of BCPRA provincial guidelines/resources, refer to
[Link]

BC Provincial Renal Agency Phone: 604-875-7340 [Link]/BCRenalAgency

(BCPRA) Email: bcpra@[Link] @BCRenalAgency
Web: [Link] [Link]/BCRenalAgency

BC Provincial Renal Agency • [Link] May 2018

 Best Practices: Peritoneal Dialysis Programs

1.0 Background and Purpose

Purpose and goals (HD) and after transplant failure. PD is utilized as the
preferred dialysis modality for pediatric patients as
The purpose of this document is to describe PD a bridge treatment to transplant. PD is an effective
practices to promote standardized, consistent and home-based therapy that provides flexibility and
integrated delivery of PD services throughout the many quality of life advantages with equitable patient
province. The development of this document utilized outcomes comparable to HD. PD eliminates the need
PD literature in combination with the expertise and for relocation to meet treatment needs, while providing
experience of PD programs in British Columbia. much lower dialysis costs (19). Peritoneal Dialysis is
the preferred type of dialysis for those with vascular
Best practice guidelines: access issues, and progressive cardiorenal syndrome.
The key benefits of PD are preservation of residual
• Incorporate evidence-based information and renal function (27), lower hospitalization (23) and lower
current practice to aid in clinical decision making access intervention rates (22) when compared to
specific to PD hemodialysis.
• Explore relationships between practice patterns
and patient outcomes to drive improvement in care Peritoneal dialysis has been recognized as a modality
• Focus on accountability to patients, infrastructure option which supports:
research, innovation, and alignment of funding to
quality patient centered care • self-management home therapy
• Develop standardized tools and practices that • integration of dialysis with work, school, hobbies
encourage self-management and jointly establish and social family activities
goals of care • flexible daily regimen
• Establish provincial standards and accountabilities • patient autonomy
to streamline the transition process and access for • flexibility in diet fluid intake
those wanting PD. • ability to travel due to portability of equipment
• potential reduction in some medications
Peritoneal dialysis (PD) is an option for renal
replacement therapy in patients with end stage kidney The BC Ministry of Health endorses a strong home
disease. It is frequently selected by patients as their therapy mandate with a provincial target of over
preferred initial mode of therapy and is an option for 30% peritoneal and home hemodialysis combined
patients transitioning from hemodialysis rate since 2010. The BC renal agency supports

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 Best Practices: Peritoneal Dialysis Programs

provincial strategies to maximize the use of home families to adjust to and manage their health and
dialysis therapies. British Columbia has adopted a peritoneal dialysis therapy
PD first approach that advocates PD as the initial • provide ongoing monitoring, support and follow
dialysis modality of choice. Current patient numbers up of patients to assist in early identification and
are available on the BC Renal Agency website (www. treatment of PD related problems
[Link]) Care for patients is provided in 13 • support planning and preparation for transition to
PD programs across 5 health authorities in BC. other renal related modalities

2.0 Target population and goals of PD 3.0 Requirements for a successful PD

programs program

The target population for Peritoneal Dialysis are those The success of a PD program is dependent on the
patients who have: development of:

• been identified as requiring dialysis • a robust and effective CKD education program that
9 BC recommendation for PD catheter offers and encourages PD as a therapy option
placement is when the GFR is between 10- • a standardized assessment process to identify and
12ml/min/1.73m2 triage appropriate patients to PD
• demonstrated an interest in peritoneal dialysis as a • transition guidelines designed to support the care
home option and preparation of patients to PD
• been assessed as being suitable candidates for • multidisciplinary patient centered support systems
home therapy PD inclusive of but not limited to: patients and families,
physicians, nursing, social work, dietitians,
PD programs work collaboratively with patients to pharmacists, occupational therapy, surgery,
provide home evidence-based, multidisciplinary PD radiology, comorbidity clinics (diabetic, cardiology,
care. A successful PD program is patient-centred to: hypertension), community support services. (PDA,
LTC, assisted living)
• support and educate patient and family to perform • access to timely PD catheter procedures
PD independently, effectively and safely in the • standardized patient training program
home environment incorporating adult learning principles
• maximize confidence and abilities of patients and • clinical practice based on current international

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 Best Practices: Peritoneal Dialysis Programs

standards Figure 1. PD Patient Flow Algorithm

• continuous quality improvement work to monitor a
variety of domains at a program, health authority Modality education

and provincial level

• structured training and continuing education for Assessment for absolute
members of the multidisciplinary PD clinical team contraindications for PD

Patient chooses PD as
treatment modality
4.0 PD milestones and patient flow
algorithm
PD referral

The major milestones and associated time lines for

patients transitioning to Peritoneal Dialysis are outlined PD suitability assessment

in Figure 1.
Self management, goal setting
and action plan development

5.0 Transition to PD PD access referral

5.1 Patient transition: adult and

PD access creation
pediatric

Transitions are common for patients with kidney failure. Implementation of PD training
for home
Patients can change from one treatment modality to
another, whether by choice or necessity. This requires
the healthcare team to anticipate and prepare patients Home implementation of PD

for these transitions. The transition from one renal

replacement therapy (RRT) can appear routine to MDT assessment/ monitoring/
providers and healthcare team members, however, treatment and evaluation

patients often express that they feel insecure and

vulnerable when they need to make a change (26).
PD retraining and ongoing
Transitions to PD can follow an urgent/ acute episode follow-up

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of kidney failure, from kidney care clinic or from Transfer to adult care occurs at the end of a transition
another modality such as transplant or hemodialysis. process that is individualized for each patient
Responsibilities for a safe and successful transition considering all aspects of growth and development.
to and from PD fall to both the multidisciplinary renal The transition process is multifaceted in nature
health care team and the patient. involving preparation of the adolescent/young adult
and the receiving adult PD program. Development of
Successful transitions to PD are dependent on: skills focusing on self management and assertion of
autonomy begins in the early adolescent years for the
• identification of the various phases of transition patient on PD. Open communication with sharing of
experienced by the patient starting PD skills and information between the pediatric and adult
• identification of roles and responsibilities of the nephrology provider is imperative for a successful
multidisciplinary PD team and patient during key transition as is the development of support structures
phases of transition and services for both programs. The International
• clear communication between all team members Society of Nephrology and the International
and patient and family Pediatric Nephrology Association have developed
• provision of consistent standardized information recommendations for clinical practice for transitions.
and practices which focusses on patient centered
care, education, goal setting, care planning and The consensus statement can be found at:
self-management [Link]

See Appendix C for On Trac Clinical Pathways Forms

See Appendix A For: Staff Transition Guide and PD For Transitioning A Pediatric Renal Patient To Adult
Patient Transition Guide Renal Care.

Pediatric transitions Additional strategies that contribute to successful

transitioning to adult care for patients/families and
Transition phases for the pediatric patient, while like health professionals can be found at:
those of the adult population, are also inclusive of: [Link]
services/transition-to-adult-care
• phases of growth and development
• transition from pediatric to adult renal care
programs

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5.2 Patient assessment for PD suitability Figu Figure

Figure 2. [Link]
PD Patient FlowtoAlgorithm
PD
and referral re 1. PD Patient Flow Algorithm
Medical Contraindications for PD
Upon demonstration of interest by the patient for PD,
the referring team conducts an initial assessment Absolute Contraindications to PD
to determine PD suitability. Contraindications for • Documented loss of peritoneal membrane
PD referral are traditionally classified as medical function or extensive abdominal adhesions that
or social (see Figure 2). If there are no absolute limit dialysate flow
contraindications, the PD team is made aware of the • Uncorrectable mechanical defects that prevent
patient’s choice and the patient is referred to the PD effective PD or increase the risk of infection
program. The patient is commonly referred to the PD (e.g. surgically irreparable hernia, stomas/
program by a nephrologist but may also be referred conduits, suprapubic G tubes, omphalocele,
from the current modality care team or nurse navigator. gastroschisis, diaphragmatic hernia and
The method (referral form, modality rounds, PROMIS) bladder extrophy, active diverticulitis)

used to refer patients to PD is program-specific. Relative Contraindications to PD

• New intra abdominal foreign bodies (abdominal
Referrals should include the following information: vascular prosthesis, recent ventricular
peritoneal shunt)
• Patient name • Intolerance to PD volumes necessary to
• Referring clinic achieve adequate PD dose
• Patient aware of referral (yes, no) • Inflammatory or ischemic bowel disease
• Current GFR (if pre-dialysis) • Severe malnutrition
• Currently on dialysis (type) • Frequent episodes of diverticulitis
• Previous abdominal surgery
• Comorbidities Social Contraindications for PD
• Modality medical contraindications
• Unmanaged active psychiatric disorders and
• Barriers to PD
social problems
• Patient lives in a residence that does not permit
On receipt of the referral, a suitability assessment
PD
is completed by the PD team. This is an integrated • Patient's spouse or family is not supportive of
assessment incorporating the perspectives of all PD PD in the home
team members: physician, RN, dietitian, social worker • Patient's residence has insufficient storage
and pharmacist. space for PD supplies and equipment

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Patients are assessed in the following domains: • Colostomy (may be candidate for pre-sternal
catheter)
• Physical • Active chemical dependency
• Cognitive • psycho-emotional capacity (e.g., lack of judgement,
• Functional cognitive decline, issues with caregiver being
• Comprehension unable to take on more)
• See Appendix D: Home Therapy Patient
The PD program suitability assessment includes the Assessment and Home Therapy Functional
identification of: Assessment

• potential barriers for successful PD and

appropriate solutions to address
• appropriate PD modality: CAPD, APD, PD Assist 6.0 PD modality options
• location for PD to be performed: home, assisted
living, long term care. 6.1 CAPD, APD, IPD
• PD catheter placement location: Referral for
catheter insertion Prescribing peritoneal dialysis begins with the
• patient’s ability and readiness to learn identification of a PD modality. Both continuous
• individualized training plan inclusive of learning ambulatory peritoneal dialysis (CAPD) and automated
objectives, content, teaching methods and aids, peritoneal dialysis (APD) are available options in British
and evaluation phases Columbia. The decision of PD modality choice is
• training schedule determined by the patient and family. Most patients
start on CAPD and transition to APD at a later date if
The following potential barriers require an in depth deemed medically appropriate and if desired by the
assessment by the PD team. It is important to be aware patient. APD is the preferred PD modality for pediatric
that some of these barriers can be addressed by patients.
providing multidisciplinary specific supports:
Evidence to date suggest that the choice of PD
• Limited mobility or manual dexterity, limited use of modality should primarily be based on patient
hands preference while providing a medically optimal PD
• Poor vision prescription. In some situations, medical suitability may
• Obesity (may be candidate for pre-sternal catheter) override preference, but in all other situations the team
• Multiple previous abdominal surgeries will try to respect the patient's preference.

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Patient preferences based on lifestyle, employment, Figure 3. Clinical pathway for CAPD
home environment, family and social support, and the and APD patients
ability to perform PD procedures should be considered.
Research indicates that there is no significant difference Patient Presents with Interest in PD
between PD modalities for outcomes related to health,
quality of life, mortality, preservation of renal function, PD PD
Patient
Patient
deemed
technique failure, adverse events, risk of peritonitis, modality suitability suitable for chooses
education assessment PD PD
adequacy outcomes, nutritional status, and anemia. (8)
APD has been associated with lower risk of transfer to
HD during renal replacement. Earlier data suggested
that APD may have a higher survival advantage over Chronic Start on PD
CAPD in high transporters; however, recent data
suggest that the peritoneal protein clearance and not Bedside catheter
insertion OR
the peritoneal membrane transport status may predict catheter insertion
(booked weeks in (booked in 1-3 months)
advance)
survival outcomes. (8)

Intermittent Peritoneal Dialysis

Week #1 Post-Catheter Implantation
Intermittent peritoneal dialysis (IPD) offered daily or
Catheter flush and dressing change
every other day is available in some programs as:
• a bridge treatment between catheter insertion
and commencement of CAPD or APD if training is
delayed
Week #2 Post-Catheter Implantation
• break in procedure for 1 week prior to PD training
• urgent start treatment for the end stage renal Catheter flush, dressing change
and suture removal
disease patient who does not have an access in
place for dialysis.
-- IPD is performed for the pediatric in-patient
requiring acute PD for volume control Week #2—3+ Post-Catheter Implantation
• temporary treatment for PD related complications
CAPD/APD training commences as per program protocols
(i.e. leaks) and timeline. CAPD may be initial modality followed
by a transition to APD at a later date based on patient
choice and clinical suitability. APD is the modality of
choice for pediatric patients

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 Best Practices: Peritoneal Dialysis Programs

Prescription management process

Figure 4. Assessing for PD
The primary goal of PD prescription management, prescriptions
regardless of modality, is to optimize patient outcomes
and quality of life. See figure 4. Assessment for PD Prescriptions

Body surface Clinical Urinary

6.2 Acute PD area (BSA) Assessment output

Urgent start PD is defined as initiation of PD in the

unplanned incident end stage renal disease patient
before the traditional waiting period of 2 or more
Consider patients preferences and lifestyle
weeks after PD catheter placement. Research indicates (CAPD or APD)
that PD is a viable option for the late presenting patient
with advanced kidney disease requiring urgent dialysis.
Figure 5 on page 10 identifies the clinical pathway for
urgent start PD.
• Aim for the lowest glucose concentration
solutions possible
Patients suitable for Urgent/Acute PD • Adjust PD prescription to volume status

• Advanced CKD without a plan for dialysis

• Patients who choose home dialysis as a long term
modality option but do not have an access in place Set prescription
• Volume overload with cardiovascular compromise
• Acute kidney injury (AKI)
• Problematic vascular access
• Hemodynamically unstable Monitor the patient regularly and adjust the
• Elderly with complex comorbidities prescription as required

Patients requiring special consideration for Urgent/

Acute PD

• Patients requiring hernia repair

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• Active intra-abdominal infection (i.e. acute than conventional HD

diverticulitis) • Facilitates discharge from hospital
• Recent abdominal surgery (within the past 6
weeks) Urgent start PD program requirements
• Recent cardiovascular thrombotic event requiring
ongoing anti-platelet therapy or anti-coagulation The success of an urgent start PD program is
(that cannot be safely interrupted for PD catheter dependent on infrastructure requirements such as:
insertion). • Objective method of patient selection
• Urgent PD catheter placement
Advantages of urgent start PD • Nursing support (training and staffing)
• Hospital and dialysis unit administrative support
• Avoidance of temporary vascular catheters • Developed policies and procedures
• Requires a single procedure for both urgent and • Space for IPD
long term access • Clinical team flexibility for rapid orientation to
• Provides the patient with the lifestyle opportunities kidney disease and peritoneal dialysis
of home dialysis • Engaged patient and family
• Allows for a gentle, incremental dialysis initiation
• Technically simpler than HD or Continuous Renal
Replacement Therapy (CRRT)
6.3 Provincial PD assist program
• Can be initiated quickly
• More cost effective
Peritoneal Dialysis Assist (PDA) is available in all health
• Less complex equipment
authorities for PD patients who meet eligibility criteria.
• Avoids vascular problems: infection, hemorrhage,
PDA is defined as the provision of assigned PD cycler
thrombosis, embolism, stenosis
tasks in the home setting utilizing trained Caregivers
• Provides time to achieve fluid electrolyte balance
(CG). Caregivers are provided training and are given
and toxin removal before training
responsibilities for each visit which include completing
• Opportunity to meet and develop relationships with
specifically assigned PDA tasks inclusive of cycler
the PD team before self managing
machine set up and dismantling. PDA can be provided
• Facilitates patient/family learning by observing
on a long term basis or as a respite/ short term service
staff performing PD therapy
in patients with temporary changes in their ability to
• Does not require anticoagulation
perform PD.
• Reduced risk of acquiring Hepatitis B and C
• Less hypotensive episodes
Patient eligibility for PDA is assessed by the
• Helps preserve residual kidney function longer
Nephrologist, PD nurse and PD social worker. Input

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from other members of the multidisciplinary team such Figure 5. Urgent start clinical pathway
as occupational therapy may be included as deemed
appropriate. Patient presents with advanced CKD without a
plan for dialysis
The PD client and/or support must:
• Complete PD training
Receives Patient
• Be able to perform the procedures related to Determined Recommen-
rapid agrees with
PD dation to
connecting and disconnecting from the cycler and modality urgent start
candidate initiate PD
education PD
associated troubleshooting of cycler complications
that may occur during the therapy.
• Be able to manage all non-cycler aspects of
their PD care inclusive of but not limited to fluid Patient referred for urgent PD catheter
placement
management, access care, effluent assessment,
supply ordering.
Catheter is placed within Catheter is placed within
• Be able to contact the PD program to communicate 24 hours at the bedside 24 hours in the OR
any identified concerns or problems associated
with their health status or PD therapy.
• Be unable to perform the cycler set up and
Initial dialysis schedule determined
dismantling procedure due to physical, cognitive,
psychological and or social reasons. See Appendix Inpatient urgent start
Outpatient urgent
E: PD Assist eligibility criteria. (pt has other reasons for
start PD
hospitalization)

Patient receives incenter low volume

6.4 PD in long-term care facilities recumbent IPD for 2 weeks
(or until ready for discharge home)
Some PD patients may require continuous, skilled
nursing care available in long-term care (LTC) facilities.
PD in a long term care facility is currently available PD training begins
in Vancouver Coastal Health Authority and Fraser Some components of
PD training may begin CAPD/APD training
Health Authority. PD education content for long-term during urgent IPD (week according to PD
care facility staff is similar to PD patient and family 2) dependent on patient program protocols
condition
education. (PD procedures, fluid balance, infectious
and non-infectious complication management) Ongoing
follow up for the patient receiving chronic PD in the Patient discharged home on full volume CAPD/
APD once training completed

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long term care facility is provided by the PD program. • Staff training

Continuing education and support are also provided to • Patient follow up
the facility staff by the PD program. • CQI initiatives
• Communication system
Advantages of PD in LTC

• Permits patients to remain on PD in their home

6.5 Pediatric PD support services
environment
• Prevents costly and inconvenient transportation to
PD nursing support service is accessible to patients
and from HD three times/week
between 0-19 years of age based on eligibility
• APD at night allows the patient to remain social
criteria through the Ministry of Children and Family
with other residents and participate in activities
Development for 12-24 hours/week. Nursing services
and rehab during the day.
covering all aspects of PD care inclusive of CAPD and
APD treatment is available to any pediatric patient/
Operational Considerations
family living within the province for respite care.

• Identify potential LTC facilities within each HA to

proactively provide PD
• Ensure that the location of the facility meets the 7.0 PD catheter implantation
population need
• Determine number of patients for sustainability of Reliable Peritoneal Dialysis access is essential to high
program quality patient outcomes. Referrals for PD catheter
• Determine number of beds required for short/long should be considered when the glomerular filtration
term needs rate (GFR) is approximately 15 mL/min/1.73m2(23) while
• Requires adequate storage to ensure adequate factoring local PD program catheter placement options,
capacity for supplies timelines and patient needs. Minimal expectation is
• Determine benefits of union vs non-union that surgical catheter insertion should be performed
environment at least 2 weeks before starting peritoneal dialysis
• Train the trainer to implement a 'train the trainer' (3). The access should be placed early to ensure the
approach for staff training patient can train for peritoneal dialysis while residual
• Clarify roles and responsibilities of the PD program renal function is adequate to avoid the need for urgent
and the LTC facility hemodialysis and a central venous catheter insertion.
• Supply ordering Repeated hospitalizations for procedures related
• Billing of supplies to the urgent need for dialysis or potential uremic

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complications because of this delay should be avoided See appendix F: Provincial Guideline: Indications
(23). and urgency criteria for surgical peritoneal dialysis
catheter access: Procedures on Adults
Randomized control trials do not exist to support one
method of implantation (3). The method of catheter b) As a “bedside” (non-surgical) procedure in a
insertion is therefore determined by a variety of factors non-surgical setting performed by a nephrologist
inclusive of patient and program circumstances. It who has had specialized training in this technique.
is suggested that positive clinical outcomes for PD This is completed as an outpatient procedure and
catheter insertion are dependent on appropriate may involve an overnight stay. Procedures are
patient selection, preparation, perioperative care and done using a local anaesthetic +/- an anti-anxiety
training. The 2010 ISPD Clinical Practice Guidelines for medication, narcotics or conscious sedation.
Peritoneal Access recommend that local expertise at
individual centres should govern the choice of method See BCPRA website for Bedside catheter insertion
of PD catheter insertion (8). guideline: [Link] Æ Health
Professionals ÆClinical Resources ÆPeritoneal
In BC, chronic PD catheters are inserted in three ways: Dialysis

a) As a surgical procedure in the operating room c) As a radiological procedure in a fluoroscopic

performed by a vascular or general surgeon. radiology setting performed by an interventional
May be done using an open incision and surgical radiologist.
dissection (laparotomy) or a laparoscopic
technique. Both are done as same day or short Regardless of the method of insertion, the exit site
stay (1 – 2 day post-operative stay) procedures and should be allowed to heal for approximately 2-3
under a general anaesthetic. The need for surgical weeks before commencing PD exchanges. Special
method involving direct vision with open insertion considerations of using small volumes with the patient
is determined by patient characteristics, such as in the supine position should be implemented if the
history of significant abdominal surgeries, the need catheter is required immediately following insertion.
for hernia repairs, vascular access failure or severe
liver disease (22). In some parts of the province,
surgical catheter insertion is the only available
8.0 Patient goal setting, training/
option for PD patients. Surgical PD catheter
education and treatment planning
insertions may include buried catheter and pre
sternal implantation as determined appropriate for
In British Columbia, initial patient PD training and
the patient and the program.

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ongoing education will be provided by a PD trained training assessment that prepares patients for PD
registered nurse with experience in teaching and training
learning. Ideally, the timing of PD teaching will be • Supportive counseling and effective
coordinated with the healing of the exit site post communication that enhances patient acceptance
catheter insertion. The International Society for of and compliance with PD treatment
Peritoneal Dialysis (ISPD) recommends that all nurses • A focus on learning objectives and training tailored
new to nephrology should receive at least 12 weeks to the unique needs of each patient
experience within a PD unit with observation of • Incorporation of goal setting and adult learning
procedures, patient education, and clinical care. PD principles
nurse trainers should be supported by continued • Prompt management of dialysis related
education to ensure skills remain up-to-date and they complications
continue to have the ability to apply the principles of • Consistent monitoring of PD training
adult learning. • Continuous patient education and retraining of
patients when necessary
Patient training for PD is an essential activity in PD
programs involving the multidisciplinary team adopting Goal-setting and treatment planning are important
evidence based practice with PD guidelines, protocols components of self-management in PD with the patient
and care standards. Individualizing patient training in the centre of the collaborative process. Important
involves: concepts to teach patients in relation to goal-setting/
treatment planning/self-management include:
• Family members and or significant other may be
included in the training to provide support for the • Strategies to incorporate goal setting into
patient treatment planning
• Modifying the length of the training sessions to • Stages of change and the relationship to setting
accommodate the patient’s ability to concentrate and achieving goals
and assimilate information without feeling • Setting SMART goals and action plans
overwhelmed • Available resources to support self-management
• Evaluating the patients progress and readiness to and goal setting
assume responsibility for home PD activities
PD training should be developed to meet the patient’s
The success of a PD training program is dependent on: individual needs by implementing a multifaceted
approach with content based on learning principles.
• Multidisciplinary team approach
• A dialysis modality education program and pre

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Learners: • discussion, follow up phone contact, web chats

• need to be free to direct themselves about what to • peer support as deemed appropriate
learn.
• appreciate an educational program that is
organized and has clearly defined elements and
8.2 Training location
goals.
• learn better when convinced of the need for
The key to a suitable teaching environment is one that
knowing the information
is physically and psychologically comfortable for the
• focus on the aspects of a lesson most useful to
learner. The dedicated space should be well lit, free
them in their everyday lives.
from minimal external distractions, large enough for
• Educators must then relate theories and
supplies, teaching aids, patient, family and PD nurse.
concepts which match the learner’s own
Appropriate locations for training may take place in:
experience and knowledge of the topic
• need to be shown respect and treated as equals.
• PD clinic
• Patient’s home
• Hospital room
8.1 PD teaching support and tools • Any location set up for specific dedicated PD
training
Teaching tools and strategies should be incorporated
into the PD training plan to meet specific individual
learning styles:
8.3 Length of training
• written materials, manuals, printed handouts,
posters Preferably a 1:1 nurse to patient approach is utilized for
• demonstrations incorporating a hands on approach initial training. The same PD RN should be involved for
• online eLearning PD modules [Link]. the duration of training for consistency. A primary care
ca Æ Health Professionals ÆClinical Resources or case management approach should be incorporated
ÆPeritoneal Dialysis post training for patients ongoing care.
• videos, audio recordings of procedures
• role playing The length of training is based on several factors;
• situational scenarios patient’s attention span, current uremic symptoms and
• PowerPoint presentations ability to process information. On average, training
• abdomen practice mannequins: dummy tummy for CAPD is usually completed in 4-5 days with an

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additional 1-2 days for APD training. Research has not • Fibrin
demonstrated a correlation between length of training • Leaks
and outcomes therefore it is suggested that training • Pain
should continue until the PD RN determines that the • Troubleshooting
patient can meet the following training objectives: • Record keeping
• Able to safely perform all required procedures • Supply ordering
• Recognizes contamination and infection • Clinic visits, labs
• Able to identify appropriate responses to specific
complications/situations
• Understands when and how to communicate with
8.5 Follow-up and retraining
the PD dialysis clinic

Follow up multidisciplinary care is a key requirement of

Training sessions should be held on consecutive
PD care. Clinic visits, telephone contacts, home visits,
days with frequent breaks scheduled according to
continuing education, community support and patient
the patients learning style and pace. Minimizing new
record keeping assist in the reassessment of patient
concepts to no more than 4 new concepts/hour is
learning needs and/or teaching.
recommended.

Ongoing education following initial training may be

provided using:
8.4 Training content
• an individual or group format
A teaching plan should include the following: • discussed as part of a PD clinic appointment(s)
• Overview of PD • during home visits
• Aseptic technique, handwashing, masking • during phone, web chat contact
• Steps in the exchange procedure
• Emergency measures for contamination Retraining of PD patients results in potential prevention
• Exit site care or reduction of PD associated complications with root
• Complications of PD cause analysis to prevent recurrence. Periodic review
• Peritonitis of hand washing technique, steps of an exchange,
• Exit site infections connection procedures and exit site care helps to
• Fluid balance identify adherence to protocols while determining
• Inflow/outflow problems if the patient’s abilities to perform procedures and
• Constipation understanding of PD concepts has changed over time.

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PD retraining is suggested following: 9.0 PD patient follow up

• Initial training on an annual basis and/or as PD patients require frequent monitoring, assessment,
identified guidance and support as they dialyze independently at
• Change in dialysis modality home. Frequency and type of follow up is tailored to
• Equipment changes the patient’s specific needs.
• Home setting changes
• Dialysis partner changes
• Change in medical condition
• Infection (peritonitis, exit site, tunnel) 9.1 Clinic appointments
• Prolonged hospitalization
• Any interruption in PD Stable adult PD patients are followed at
multidisciplinary clinic appointments at a minimum of
every 3-4 months. Pediatric patients are seen every
4-6 weeks. Frequency of clinic appointments are
8.6 Home visits determined by the multidisciplinary team based on
patient care needs and preferences, ability of patient
While research is limited in drawing correlations to self-manage and geographic distance to the clinic.
between home visits with clinical outcomes; it is Clinic appointments are a collaborative process. The
recommended that home visits be scheduled as part of patient assessment includes but is not limited to:
patient care when deemed necessary and possible to
achieve. Benefits of home visits provide visualization • Medical
and insight into the adaptation of PD into the patient’s • Comprehensive physical assessment/change
daily life permitting the ability to alter or modify in physical status/ comorbidity and symptom
treatment parameters to achieve positive clinical review
outcomes. • SOB, Chest pain, muscle cramps,
constipation, diarrhea, pruritus, appetite
Considerations for home visits include: changes, nausea/vomiting, insomnia,
restless legs, pain, falls
• Post lengthy hospitalizations • Vital signs
• Post peritonitis episodes • PD regimen and current prescription
• Identified changes in patients/family’s ability to self • Exit site assessment
manage, and/or cope with aspects of care • Catheter function
• Evidence of care giver burn out • Volume status

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• Peritoneal ultrafiltration, solute transport

(Adequacy/PET/ 24 hour urine)
• Peritonitis/exit site and tunnel infections
• Culture results
• Foot assessment
• Review of recent hospitalizations
• Exercise routine
• Transplant status
• Chemistry and hematology review
• Diagnostic testing
• Psycho social review (patient and family support)
• Nutritional assessment and management
• Medication review
• Patient goal setting
• Learning needs and continuing education when
indicated
• PD technique review

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9.2 Laboratory testing

The following tests are recommended; however, type

of test and frequency is at the discretion of each PD
program and health authority and the need of the
patient.

INITIATION EVERY 3 EVERY 6

ADULT PD PATIENT OF PD
MONTHLY
MONTHS MONTHS
ANNUALLY

CBC, Na, K+, Cl-, Ca2+, PO4, HCO3-, BUN, Albumin,

RBS, Creatinine

HbA1C (diabetics), Ferritin, Fe, TIBC, %Sat., PTH

AST, Alk Phos

TSH, HbsAg, AntiHBs,AntiHBc, HCV

Lipid profile

Transplant antibodies (if applicable)

Peritoneal equilibration test (PET): performed 4-6 PRN

wks. post training and then PRN
24 hour adequacy collection: (dialysate and PRN
urine) performed 4-6 wks. post training and PRN
following

24 hour urine collection (if applicable)

ARO testing

Viral Hepatitis B, C, HIV

TB screening (questionnaire, chest x ray, interferon

gamma release assay)

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INITIATION EVERY 3 EVERY 6

PEDIATRIC PD PATIENT OF PD
MONTHLY
MONTHS MONTHS
ANNUALLY

BUN, Cr, Na, K, Cl, HCO3, Mg,

glucose, Ca, iCa PO4, alk phos, albumin, CRP,
PTH, CBC, diff, platelets, retic count, Fe, ferritin,
transferrin sat
Uric acid, Vit B12, TSH, total protein, 1,25 dihydroxy,
0,25 hydroxy

Hep C, Hep A, HSV, CMV, EBV, VZV, MMR,

cholesterol (HDL/LDL),
triglycerides, selenium, zinc, AST, ALT, GGT,
billirubin (conj/unconj)

Anti-HBs, HBsAg, Total Anti-HBc, HIV

Transplant antibodies (if applicable)

Peritoneal equilibration test (PET): performed when

patient reaches optimal fill volume (4-8 weeks post
PD initiation)

24-hour adequacy collection: (dialysate and urine)

with PET and every 6 months following

24-hour urine collection (if applicable) performed

with PET and every 3 months following

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10.0 PD guidelines and protocols 10.2 Provincial standardized PD

protocols
Evidence based practice is a principal element in
achieving positive clinical outcomes. The availability BC standardized protocols and procedures are
of PD guidelines, protocols and standards at a developed by the BCPRA PD committee and the PD
local, provincial and international level are to be RN group. These procedures are based on current
implemented to provide standardized, safe, efficient, evidence and experience. PD procedures for the adult
cost effective, and quality care for the patient on PD. population can be found at: [Link] Æ
Health Professionals ÆClinical Resources ÆPeritoneal
Dialysis

10.1 International Society for Peritoneal Pediatric PD procedures can be found at:
Dialysis (ISPD) Guidelines [Link] Æ Health Professionals
ÆClinical Resources ÆPeritoneal Dialysis
The International Society for Peritoneal Dialysis (ISPD)
has developed several adult and pediatric guidelines [Link]
that support best practice in PD. Guidelines can be
found on the ISPD website ([Link]) for the following
guidelines:
10.3 PD provincial and program
• Acute Kidney Injury evaluation and recommended
• Cardiovascular and Metabolic guidelines outcome indicators
• Encapsulating peritoneal sclerosis
• Infection recommendations (adult and pediatric) Key performance indicators in three primary categories
• Peritoneal access of recruitment, retention and maintenance are
• Solute and fluid removal evaluated at a Provincial and program level. An
• PD training annual gap analysis identifies quality improvement
• Assessment of growth and nutritional status in opportunities and supports the development of
children associated action plans to support quality PD care.
• Elective chronic peritoneal dialysis in pediatric
patients Clinical practice changes over time. Monitoring,
surveillance and regular analysis are an integral part
of informing that change. Quality or performance
indicators can be monitored at a higher level (e.g. PD

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committee, BCPRA executive, PHSA/MoH Board) to set of indicators are reported to PHSA Board (Peritonitis
facilitate the design and funding of programs, as well Rate, % dialysis patients on PD or Home HD) and
as to ensure effectiveness and efficiency of overall PD Ministry of Health (% dialysis patients on PD or Home
care delivery. More importantly, these same indicators HD). They will be reviewed by the Provincial PD
should be used at the program level to create and Committee. These are often “background” program
maintain PD programs that meet patient needs, statistics that may not be acted on at the program level
promote excellence in clinical care and explore ways however, are necessary to ensure consistency and
to improve all aspects of the health care system for monitor trends over time
patients and providers.
Recruitment
These processes ask questions such as:
• Number of PD referrals - % PD intake
• Is what I am doing right now worthwhile? Is it -- GFR at referral
improving patient care? -- GFR at start of dialysis
• What should we be doing to improve patient care • % pts starting PD as preferred modality choice
that we are not currently doing? -- Reasons for pts who did not initiate PD as
• How effective is our program? preferred modality choice:
• How do we compare to other programs? • Changed mind
• What are we doing that is unique and we could • Change in eligibility
share with other programs? • Acute deterioration of GFR and started HD
• Do we meet local, national and international -- Number of patients who transferred to
standards? PD after HD start
• What is missing from our program that we believe -- Timing of transfer to PD after HD start
will improve care? How can we demonstrate that? • Recovered renal function
• Transplant
• Death

10.3.1 Provincial key performance Retention/maintenance

indicators
• % prevalent patient
Provincial indicators are to be summarized with BC as a • Unexpected early attrition
whole. The report will be generated and maintained by -- PD exits at 6 months post commencement of
the Provincial Renal Agency and will be disseminated PD therapy
to PD programs at predetermined intervals. A selected -- PD exits at 1 year post commencement of PD

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therapy -- Recovered function

• Cause specific PD attrition rates by reasons • Hospitalizations
-- all PD exits -- Reason
• # patients having temporary HD annually--reason -- Length of hospitalization
• # PD exits each year by reasons -- Modality discharge status
-- Death / dialysis withdrawal • PD assist outcomes
-- Death within 1 month of PD initiation -- Number of referrals
-- Transplantation: -- Long term
• PD not suitable (Transfer to HD) -- Respite
Infection • Number of PD patient using PDA service
• Catheter related problems -- Demographics (compared to provincial PD
• Inadequate dialysis population):
• Catheter unrelated Abdominal • Age
complications • Gender
• Psychosocial • Diagnosis
-- Comorbidities -- Length of time on PDA
-- Move -- Reasons for exiting long term care PDA:
-- Lost to follow up • Death
-- Recovered function • Conservative management
• 1 year PD survival rate (length of time on therapy) • Technique failure
• Infection rates • Social reasons
-- Peritonitis • Returned to independent home pd
-- Exit site • Long term care placement
-- Tunnel -- Hospitalizations
-- Causative organism • Reason
• Catheter insertion • Length of hospitalization
-- Bedside • Modality discharge status
-- Surgical
• GFR at time of catheter insertion
• Catheter removal rates by reason
-- Infection
-- Catheter related problems
-- Inadequate dialysis
-- Catheter unrelated abdominal complications
-- Psychosocial
-- Comorbidities
-- Transplant

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10.3.2 PD program key performance Maintenance/Retention

indicators
• Number of prevalent PD pts
Program indicators may be collected by the PRA and/ -- Number of patients at Home
or the PD programs. It is recommended that each -- Number of patients on PD in Long term care
program review quality indicators twice yearly or if a -- Number of patients receiving PD assist
clinical question/event indicates that a review may be • Number of patients meeting ISPD guideline targets
needed (i.e.: a sudden change in exit site infections for -- Solute and fluid removal
example). -- PD specific infection rates
• Peritonitis
These indicators could also be used to identify quality • Exit site
• Tunnel
improvement projects that would guide practice and
• Causative organisms
clinical guidelines in the future. These can be shared
-- Anemia management
with all the programs across the province and at
-- Bone mineral metabolism
international meetings.
• Hospitalization rates and reasons
• Temporary transfer to HD—reasons and time
The following key performance indicators are listed
• Quality of life
as potential considerations for review by each PD
-- A suggested measure of Quality of Life (QoL) is
program.
the use of a modified version of the Edmonton
Symptom Assessment System (ESAS) which is
Recruitment
well-accepted for assessing the physical and
psychological symptoms of patients with End
• Total number of referrals to PD
Stage Renal Disease. When administered on
• Time from access referral to access creation
a regular basis, the ESAS tracks changes in
• Time from referral for dialysis initiation to initiation
the severity of symptoms, which will trigger
of training
an action plan on the part of the PD team. This
• Acute vs planned start
tool can be found at: [Link]
• Number of patients starting on PD as a preferred
–Health Info –Managing My Care
modality
–Symptom Assessment and Management
• Number of patients transitioning to PD from other
• Unexpected early attrition
modalities
-- PD exits at 6 months post commencement of
• Total number of PD starts (PD uptake)
PD therapy
-- PD exits at 1 year post commencement of PD
therapy

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• Cause specific PD attrition rates by reasons -- Abdominal complications

-- All PD exits -- Psychosocial
• Death / dialysis withdrawal -- Medical reasons
• Death within 1 month of PD initiation -- Transplant
• Transplantation -- Recovered function
-- PD not suitable (permanent • Catheter insertion complications
transfer to HD) -- Perioperative complications
-- PD Infection • Bowel perforation and/or significant
-- Catheter-related problems hemorrhage
• Initial nonfunction -- Early infections within 2 weeks of catheter
• Migration insertion
-- Solute/water clearance -- Dialysate leak
-- Abdominal complications -- Catheter dysfunction at the time of first
-- Psychosocial use requiring catheter manipulation or
• Loss of caregiver, replacement
• Unable to cope • Number of patients requiring temporary HD
-- Medical reasons—comorbidities -- Percentage and timing of patients who return
• Move to PD following temporary HD
• Lost to follow up • Number of patients trained on PD
• Recovered function • Number and reason of patients initiating training
• 1 year PD survival rate (length of time on therapy) but not completing
• Infection rates • Length of PD training
-- Peritonitis • Number and reason of patients retrained on PD
-- Exit site • Number and indications for home visits
-- Tunnel
• Catheter insertion
-- Bedside
-- Surgical
-- Radiology
-- GFR at time of catheter insertion
• Catheter removal rates by reason
-- Infection
-- Catheter related problems-
-- Solute/UF clearance

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11.0 Advance Care Planning outcomes of renal replacement therapies and

alternative plans of care.
In September 2011, legislation came into effect to 2. To define the patient’s key priorities in EOL care
provide British Columbians with improved options and develop a care plan that addresses these
for expressing their wishes about future health care issues. Advance care planning is an effective tool
decisions. This legislation allows capable adults for facilitating communication among patients,
to put plans into place that outline the health care their families and the health care team and is
treatments they consent to or refuse based on their integral to providing high quality dialysis care.
beliefs, values and wishes. 3. To enhance patient autonomy by shaping future
clinical care to fit the patient’s preferences and
The province of British Columbia and the BC Ministry values.
of Health, in partnership with BC health authorities
4. To improve the health care decision process
and health care providers, developed and published a
generally, including patient and family satisfaction.
resource for British Columbians to help with advance
5. To identify a substitute decision-maker for future
care planning (ACP).
medical decision-making (as appropriate).
6. To help the substitute decision-maker understand
The advance care planning guide can be found at:
their role in future medical decision-making.
My Voice: Expressing My Wishes for Future Health Care
Treatment 7. To promote a shared understanding of relevant
values and preferences among the patient,
To assist patients, use the My Voice planning guide: substitute decision-maker and health care
My Voice companion providers.

The BCPRA has prioritized the advance care planning Visit the BCPRA website for more information:
process as an essential part of renal care. ACP [Link] – Health Professionals –
discussions should take place throughout the patient Clinical Resources – Palliative Care
journey and be revisited every time a patient’s medical
condition changes. Advance Care Planning Documentation

The primary goals of ACP are: Documentation is an essential component to ACP.

Documented discussions will improve the care of
1. To enhance patient and family understanding of patients entering the final stages of their lives through:
their End Stage Renal Disease (ESRD) and End of • Gathering information about ACP activities that
Life (EOL) issues, including prognosis and likely have occurred throughout the life of the renal

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patient Guides to assist with symptom burden for both health

• Track activities as the patient interact with any BC care professionals and patients can be found at:
renal program and modality (i.e. CKD, HD, HHD, [Link] –Health Info –Managing My
PD, Transplant) Care –Symptom Assessment and Management
• Offer a report that may assist programs identify
patients who may need focus on ACP activities
based on GFR levels
11.1 Pediatric considerations for the
Documenting ACP discussions must be entered in appropriate choice of conservative
care or renal replacement therapy
PROMIS. The diagram on page 27 will help the user
navigate the PROMIS module for ACP. The ACP module
An ethical decision-making framework for the
in PROMIS is not a comprehensive charting tool for
appropriate choice of conservative care or renal
ACP- it is a tracking tool for patient and program
replacement in infants and children with ESRD has
planning purposes. Entering this information will
been developed to help determine if the burdens of
later assist in identifying which PD patients still need
dialysis outweigh the benefits for a pediatric patient
conversations as well as help improve the services
and family. The framework helps guide the discussion
offered to all patients.
between the healthcare team and family factoring
medical considerations, quality of life determinants,
Symptom Assessment and Management
patient and family preferences and contextual features.
Summary recommendations for shared decision-
The symptom burden of PD patients can be extensive,
making regarding the withholding and withdrawing of
severe and with significant impact on quality of life.
dialysis in pediatric practice: (5)
The Modified Edmonton Symptom Assessment System
(mESAS) has been recognized in the literature as and
Recommendation 1: Develop a patient–physician
effective tool for assessing symptoms in ESRD patients
relationship that promotes family-centered shared
and is recommended to be completed on a routine
decision-making for all pediatric patients with AKI, CKD,
basis with all renal patients.
and ESRD.

The mESAS can be found on the BCPRA website at:

Recommendation 2: Fully inform patients with AKI,
[Link] –Health Info –Managing My
stage 4 or stage 5 CKD, or ESRD and their parents
Care –Symptom Assessment and Management
about the diagnosis, prognosis, and all appropriate
treatment options. Inform children and adolescents in
a developmentally appropriate manner, and if feasible,
seek their assent about treatment decisions.

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Advance Care Planning Module (PROMIS)

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Recommendation 3: Facilitate informed decisions not be of benefit or the burdens would outweigh the
about dialysis for pediatric patients with AKI, CKD, or benefit.
ESRD, discuss prognosis, potential complications, and
quality of life with the patient, parents and/or legal Recommendation 8: Consider the use of a time-
guardian. limited trial of dialysis in neonates, infants, children,
and adolescents with AKI or ESRD to allow for the
Recommendation 4: Establish a systematic assessment of extent of recovery from an underlying
due process approach for conflict resolution if disorder.
disagreements occur about dialysis decisions. Use
conflict resolution interventions when family members Recommendation 9: Develop a palliative care plan
disagree with one another, when children disagree with for all pediatric patients with ESRD from the time
their parents, when families disagree with the health of diagnosis and for children with AKI who forgo
care team, or when the health care team disagrees dialysis. The development of a palliative care plan is a
about initiating, not initiating, or withdrawing dialysis. continuation of the process of advance care planning
and should be family-centered.
Recommendation 5: Institute family-centered
advance care planning for children and adolescents
with AKI, CKD, and ESRD. The plan should establish
treatment goals based on a child’s medical condition 12.0 PD multidisciplinary healthcare
and prognosis. team: roles and responsibilities

Recommendation 6: Forgo dialysis if initiating or The PD multidisciplinary health care team includes:
continuing dialysis is deemed to be harmful, of no • Nephrologist
benefit, or merely prolongs a child’s dying process. The • Registered nurse
decision to forgo dialysis must be made in consultation • Registered dietitian
with the child’s parents. Give children and adolescents • Registered social worker
the opportunity to participate in the decision to forgo • Pharmacist/pharmacy tech
dialysis to the extent that their developmental abilities • Licensed practical nurse (LPN)
and health status allow. • Unit clerk

Recommendation 7: Consider forgoing dialysis in Additional team members for pediatric programs
a patient with a terminal illness whose long-term includes:
prognosis is poor if the patient and family are in • Psychologist
agreement with the physician that dialysis would • Child life specialist

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12.1 Peritoneal dialysis team functions 12.3 Registered Nurse

A successful PD program is dependent on the expertise The PD nurse has many important roles, including that
of all members of the multidisciplinary team, thereby of a patient caregiver, educator, and care coordinator.
maximizing the utilization as well as quality of PD. All The PD nurse provides ongoing education and support
members should work in collaboration with patients for patients throughout their PD journey and ensures
and their families to develop patient-centered continuity of care between the patient and wider
management plans, goal setting and advanced healthcare team incorporating a case management
care planning. To ensure effective and cohesive approach. The RN is integral at maintaining and
teamwork among PD team members, definition and managing relationships and communication between
understanding of individuals’ roles is important. PD product vendors and the PD program and patients.
Patients often rely on their PD nurse as the principal
source of advice on many aspects of treatment.

12.2 Nephrologist

Nephrologists may be involved with the patients’ 12.4 Registered Dietitian

transition to PD from pre- dialysis care or from an
alternative modality of renal replacement therapy. The significant role of nutrition in the care of dialysis
Often, the nephrologist specializing in PD care can patients is well documented. The registered dietitian
differ from the patient’s primary nephrologist, and provides education and clinical guidance to assess
transition of care should occur between physicians patients’ nutritional needs, develop and implement
once the patient has undergone PD catheter individual nutrition programs and monitor and evaluate
insertion. Nephrologists work in partnership with the patients’ response.
the multidisciplinary team to establish therapeutic
relationships which focus on delivering patient
centred care. They play important roles in pre-dialysis
counselling, catheter insertions, patient treatment, and 12.5 Registered Social Worker
quality management, among others.
The registered social worker is essential to the
wellbeing of patients as they transition and adjust to
all phases of renal care. They work collaboratively with
the healthcare team to develop a plan of care inclusive
of assessment, support, consultative and direct

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services to address patient needs related to high social Description of specific roles and responsibilities can
determinants of health and risk factors in adaptation to be obtained by contacting the lead chairperson for
chronic illness, self-care and self-management. each discipline. Information can found by contacting:
[Link]

12.6 Pharmacist
13.0 Health care clinician training
Peritoneal dialysis patients often require multiple
pharmacotherapies and complicated drug regiments Initial and ongoing training and education is a key
to manage their condition. The pharmacist works component of a successful PD program. A variety of
in collaboration to provide medication compliance educational support opportunities are available for
counseling, drug interaction screening, medication all members of the multidisciplinary team at a local,
reconciliation, evaluation and interpretation of drug provincial, national and international level. Resources
level assays, education for staff and patients and to consider are structured training programs,
enhanced overall medication management. continuing education opportunities, mentorship
from senior members of the multidisciplinary team,
conferences and literature/internet resources.

12.7 Licensed practical nurse (LPN)

The LPN works collaboratively with the RN to perform 13.1 Resources

procedures for PD patients with stable and predictable
states of health. The LPN can work in PD programs • Advanced nursing online PD course offered by
after successfully completing unit specific training in BC Institute of Technology (BCIT) PD education.
peritoneal dialysis. Funding is provided by the BCPRA for the newly
hired nurse working on a PD unit and/or current
PD nurses seeking additional professional
development training. Course content and
12.8 Unit Co-ordinator (Unit Clerk) objectives can be sourced at: [Link]
• A full discussion of adult learning can be found in
The unit clerk provides administrative support to the ISPD guidelines - ISPD and the University of
ensure day to day operations of PD programs are Pittsburgh -Teaching Nurses to Teach: Peritoneal
seamless and efficient. Dialysis Training: [Link]

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• ISPD Guidelines- Peritoneal Dialysis Patient • Renal Fellow Network-National Kidney Foundation:
Training -2006: [Link] [Link]
curriculum/ • American Society of Nephrology- Career Resource
• CANNT nursing standards: [Link] Videos: [Link]
• Industry provided specific training programs and • American Society of Nephrology - Dialysis Virtual
information. Mentor [Link]
• Baxter- PD University: [Link] training/mentors/

• Baxter- Home Therapies Institute/Team PD: http:// • Peritoneal Dialysis Academy: [Link]
[Link] medicine/nephrology/

• Introduction to PD Catheter Insertion Course- • Tools for Detection, Monitoring and Referral of
Kidney Campus, McMaster University is suggested: CKD: [Link]
[Link] • Continuing medical education (CME) individual
• PD University for Interventionist Nephrologists and activities for family physicians: [Link]
Interventionist Radiologists is another option for [Link]/professionals/physicians
Nephrologists: [Link] • Chronic Kidney Disease Education webinars to
• Canadian Society of Nephrology (CSN): https:// General Practitioners are offered on a quarterly
[Link] basis: [Link]

• ISPD Home dialysis University: [Link]

• You Tube: [Link]
• The Kidney Research Scientist Core Education 13.2 Conferences
and National Training Program (KRESENT): www.
[Link] Annual conferences are designed to provide continuing
education on relevant renal subjects targeting the
• American Society of Nephrology (ASN) Education
multidisciplinary team. The following recommended
and Meetings: [Link]
renal conferences include:
• Royal College of Physicians- CPD Program
Accreditation- Provider of continuing professional
British Columbia
development for the maintenance of certification
• Western Canada PD Days [Link]
(MOC) [Link]
• BC Kidney Days [Link]/bc-kidney-days
• The ISPD Fellowship Courses: [Link]
• Peritoneal Dialysis Curriculum: [Link] National
education/pd-curriculum • Canadian Society of Nephrology (CSN) [Link]

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• Canadian Associations of Nephrology Nurses and budget in partnership with the health authority renal
Technicians (CANNT) [Link] programs. Once renal funding is delivered to a health
authority, the funds can be used at the discretion
North American of its renal program, allowing the ability to address
• Annual Dialysis Conference regional targets in view of local circumstances. By
[Link] accommodating both province-wide and regional
• American Nephrology Nurse Associations (ANNA) targets, the BCPRA funding model ensures that health
[Link] authorities can address local needs, while also meeting
provincial objectives for renal care. The transparency
International of the funding model enables the direct comparison of
• International Society of Peritoneal Dialysis (ISPD) patient outcomes by location across the province and
[Link] the fair evaluation of non-standard approaches to care.
• European Renal Association-European Dialysis (17)
and Transplant Association (ERA-EDTA) [Link]
[Link]/ Funding provided to a Peritoneal Dialysis program is
based on projections of patient volumes for:

• Entry into treatment (per new case),

14.0 Recommended allocation of • Maintenance care (per patient year) and
resources for PD
• Exit from program (per discharge)
14.1 BCPRA PD Funding Model
Funding provided for new, discharged and/or
maintenance cases is based on:
The funding for PD service delivery is provided by
the ministry of Health and allocated based on patient • Task/activities required by patients under each
volumes. The mandate of BCPRA is to advocate case category (the intensity of medical care
for funding to support delivery of services in an depends on acuity level)
equitable manner throughout the province. Operation • Most appropriate type of staff to do each task
and delivery of services is the responsibility of the
• Amount of time to complete each task
health authority renal programs. In 2003, BCPRA
developed an activity-based funding approach for • Frequency of completing the task (e.g. every
kidney patients with the overarching objective of month, upon entry, upon discharge etc.; and
establishing a sustainable model for renal services. • Probability that the task will be required for the
BCPRA is accountable for the entire provincial renal patient population

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See Appendix G, table 1 and 2 for examples of the 14.3 PD staffing/patient funding ratios
tasks related to peritoneal dialysis. Table 3 provides
an example of the Acuity Level tool to determine the
Programs are to use a multidisciplinary approach
amount of work required.
to identify patient needs and to overcome barriers
to PD in the home. Programs in the province have
comparable multidisciplinary clinical and administrative
14.2 Application of the BCPRA PD staffing needs. These include clinical and operational
funding model leadership, nephrology consult services and access
BCPRA’s Activity Based funding model is founded on to a team of nurses, dietitians, pharmacists, social
the concept of: workers and clerical staff. An average staffing mix
is determined by the current activity based funding
• funding follows the patient model, but individual programs can tailor it as they see
• funding is based on outcomes fit. See chart on page 34.

The funding model covers the costs of delivering

multidisciplinary care for all patients with kidney
disease in British Columbia, regardless of their location 15.0 PD supply and service delivery
or treatment modality. The BCPRA’s activity model
15.1 Roles and responsibilities
describes each care activity required, identifies the
staff needed to complete the activity, estimates the 15.1.1 Vendor
time required for completion (validated by time motion
studies), defines the frequency of the activity and • For home patients, the vendor will assume
estimates the probability of the activity being required responsibility for the integration of products,
for patients in each treatment modality. The number supplies, and PD services according to a
of direct patient care hours required for each category negotiated provincial contract. Services include full
of care provider was determined. Hours were then service delivery of all PD related equipment and
converted to FTE requirements and corresponding supplies for home patients. The vendor will assume
labour costs after adjusting for fatigue and delay that all delivered supplies are:
factors, indirect patient care activities, sick time,
• Within shelf life ranging from 12-24 months.
statutory holidays, vacation time and professional
• Rotate and put away stock in patient’s designated
development time.
dialysis or storage area
• Products are as specified, and that the products

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Funding Ratios: Total FTES per 100 new cases for HD, HDD, PD and pre-dialysis

are clearly labelled, are new and have not been 15.1.2 PD program
used, demonstrated or reconditioned
• Delivered in a timely manner in accordance within Ideal supply stock levels for PD programs are
the patient schedule maintained by the hospital stores departments in most
• Notify the patient and training centre of any hospital-based PD programs. PD staff may be required
inabilities to meet undeliverable time lines. to use a dedicated inventory system to determine the
amount of stock required for a functioning PD clinic.
The vendor will support home patients by:
In community-based clinics, the training nurse may be
• Providing delivery and customer service to all responsible for ordering all PD training supplies and
home PD patients ancillaries through the vendor.
• The vendor will offer easy to access customer care
for assistance with supply ordering To ensure efficacy in PD supply and delivery, the PD RN
/supply coordinator will be responsible to:
• Order and coordinate arrangements for initial
home dialysis patient supply order
• Order unique, or patient specific supplies, from the
hospital purchasing department or vendor

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• Rotate stock and noting expiry dates if not done by 15.1.4 BCPRA
hospital stores departments
• Store all supplies according to vendor The BCPRA is responsible for:
recommendations
• Ensure all patient prescription changes are • Coordination of the provincial PD program in
communicated to vendor in a timely manner collaboration with all peritoneal programs
• PD provincial contracts
• Financial costs for all peritoneal dialysis supplies
15.1.3 Patient and products.
• Coverage of travel costs for PD patients
• The PD team will determine the patient’s supply
order based on prescription and ancillary needs.
Upon completion of training, the patient will be
15.1.5 Purchaser
responsible to:
• Order supplies according to delivery schedule. Each Health Authority is responsible for purchasing
A minimum of 5 business is required for orders PD training supplies and ancillaries. Orders are to be
to be placed. placed directly with the vendor.
• Store all supplies according to vendor
recommendations
• Sort supplies and note expiry dates 15.2 Contract
• Use products accordingly to prescription
15.2.1 Process
• Ensure availability of someone in the home to
receive supply deliveries.
The provincial contract provides supplies to patients
• Allow 60 days’ notice for travel. Discuss travel
with financial coverage by the BCPRA. The Peritoneal
plans with PD team.
Dialysis Committee, BCPRA and BCCSS reviews
evidence-based products using specific evaluation
criteria to identify the product that delivers the greatest
overall clinical, technical and financial value.

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15.2.2 Expectations

A set of quantifiable key performance indicators are

used to ensure efficiency, capability and effectiveness
of various operational aspects of the contract.

15.2.3 Monitoring

The BCPRA will manage, and monitor the Provincial PD

contract, and facilitate the contract with BC Clinical and
Support Services (BCCSS). Key performance indicators
will be reviewed at quarterly business meetings

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16.0 Appendices
Appendix A: Transition to Peritoneal Dialysis
PD can be performed as self-care or care by companion/caregiver in a patient’s home or care facility.
Note: *identifies tasks that may be done by the referring Team or PD Team or link/transition/navigator nurse or designated other.
Division of duties is arranged locally.

Major Tasks
Phase Referring Team (TX, HD, HDD) PD Team
1. Identifies Identifies patients who are interested and eligible
patients interest for PD using basic eligibility criteria.
and eligibility • See Best Practices for PD Programs-Figure 2,
for PD page 5 for basic PD eligibility criteria
• See [Link]/health-
professionals/clinical-resources/modality-
choices and [Link]/
health-info/managing-my-care/chronic-
kidney-disease-(ckd) for information on
Modality Choices

2. Patient referral Refers eligible PD candidates to PD for PD Receives patient referral.

to PD suitability assessment. Updates PROMIS.
Books appointment for:
→ • PD suitability assessment
← • Meeting with PD training nurse

Communicates dates and details of appointments

with patient and referring team.

3. PD suitability *Conducts PD suitability assessment

assessment • See Appendix D of Best Practices for PD
and modality programs for example of PD assessment tool
education
*If assessed as suitable, provides a basic overview/
education of PD
• See Best Practices for PD programs page 12-15
for examples of PD modality education topics for
review
• See [Link]
professionals/clinical-resources/pd-patient-
training-modules for PD e-learning modules

Advises patient & referring team of PD assessment

outcome. Updates assessment outcomes in PROMIS.

Maintains current list of patients suitable for PD.

↓ ↓
continued...

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4. PD start Regularly reviews status of patients with PD as Develops PD patient care plan outlining expectations
anticipated planned modality. and planning for catheter insertion, PD training, self-
within 6 months management responsibilities.
↓ ↓
If status or home situation changes that may Reviews PD care plan with patient if concerns flagged
impact suitability for PD1, notifies PD team. → by referring team. Advises referring team of changes
← in care plan.
↓ ↓
Provides ongoing patient care and follow up re:
hemodialysis, home hemodialysis, medications,
lab results, diagnostic imaging, comorbid
management, psycho social support until the
commencement of PD training. Updates PROMIS
accordingly.
↓ ↓
Ensures advance care planning discussion has
been initiated & documented.
↓ ↓
5. PD catheter *Refers patient for PD catheter insertion Liaises with referring team re timing & arrangements
insertion referral for PD catheter insertion as required
and patient GOAL: if bedside insertion, 2 wks. prior to starting →
preparation PD; if OR insertion, at GFR 12 – 15 mL/min2. ←
Advises patient & PD team
↓ ↓
*Prepares patients for PD catheter insertion, including
the provision of information on:
• location and time of catheter implantation
• pre-implantation preparation
• marking of PD catheter placement
• implantation procedure
• transportation
• post implantation medications
• post implantation complications and
management
-- See [Link] for
patient education/care for PD catheter
implantation

Books appointments for post catheter implantation

care.

Advises patient and referring team. Updates PROMIS

↓ ↓
continued...
1
Changes in: living status/accommodation, availability of support to assist with PD, ability to self-manage, physical status, cognitive status, decision to
do PD, awareness of knowledge to comprehend and carry out responsibilities associated with PD.
2
Timing of bedside insertion is more flexible and is decided between the patient, nephrologist and PD team.

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6. Post-PD catheter * Assumes responsibility to perform or designate post

implantation implantation catheter care and associated patient
management education inclusive of:
• Catheter flushes
• Exit site care/dressing changes
• Exit site assessments
• Suture removal
-- See [Link] for
applicable policy and procedures

Updates PROMIS.

Books PD training:
• Start date
• Location
• Length of training
• Training objectives and expectations

Updates PROMIS.
↓ ↓
7. Transfer of care Completes transfer of care documentation: Assumes responsibility for all ongoing care on
to PD team • Transition package commencement of first day of PD training inclusive of:
• Arranges for relevant sections of chart to be • HD catheter care and removal
copied • Arranges for back up HD treatments as required.
• Reviews mobile labs
→ Initiates PD training.
Advises patient & patient’s primary care physician
re next steps. Updates PROMIS. Advises primary care physician re PD plans.

Updates PROMIS.

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Appendix B: Transitioning to Peritoneal Dialysis-Patient guide

Transitioning
to Peritoneal
Dialysis

View/download the full booklet on the BCPRA website:

[Link] ÆHealth Info Æ Managing my Care Æ Peritoneal Dialysis
Æ Resources for Current Patients

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Appendix C: Pediatric transition to Adult Care

On Trac Transition Clinical Pathway (Complex) Renal/Dialysis/Transplant

ONTRAC TRANSITION CLINICAL PATHWAY (COMPLEX)

RENAL/DIALYSIS/TRANSPLANT
DATE INITIATED ___/___/_____ DATE LAST CLINIC VISIT ___/___/_____
DD MM YYYY DD MM YYYY

Preferred Name____________________________________________ Transfer Information Checklist

Date of Birth _____________________PHN#____________________
Initiating Clinic_____________________________________________

Practitioner

Specialist
These people have been sent the most

Family
Family
Youth/

Adult
Diagnosis Primary_______________________________________ recent attachments (where applicable):
Secondary _______________________________________________
Youth Email_______________________________________________ Medical Transfer Summary
Youth Cell #_______________________________________________ Adult Clinic/ Office Information
Relevant recent Lab Reports and Flow
Mailing Address____________________________________________ sheets
Urinalysis, ACR or proteinuria
Contacts Radiology Reports (Eg. nGFR, Renal U/S)
Preferred Contact __________________________________________
Biopsy Reports (if available)
Phone ___________________________________________________
ECHOs, ECG
Emergency Contact (if different) ______________________________ All relevant Consult Letters
Phone ___________________________________________________ Psychology Assessment
Special Considerations Social Work Assessment
Nutritional Reports
Need Interpreter Yes__ Language______________ Non-verbal ____
Individual Care Plans (Nursing Support)
Safety___________________________________________________ Transition Care Management Plans
Mobility__________________________________________________ C&W Authorization for Release of
Information Consent Form
Behavior____________________________________ Aggressive____
Current School____________________________________________
Cognitive Level at grade level Yes  No 
Individual Education Plan (IEP) Yes  No 
Psycho-educational/Cognitive Assessment (Month/Year)___________
Post-secondary Plans School_____ Work _____ Other_____ Consents
First Nations Status Yes  No  I agree to be contacted about my transition experience up to five years after
leaving BC Children’s Hospital
Financial/Medication Assistance Yes  No  Youth Signature ___________________ _______________________________
Contact__________________________________________________ Date ____________________________
MSP Fair Pharmacare Non-Insured Health Benefits (NIHB) Or Guardian/Representative Signature_________________________________

Extended Health Benefits ____________________________________

Advanced Directives _______________________________________
Eligibility CLBC CSIL PWD

Youth’s strengths and concerns on transfer (to be completed by youth, parent/family and/or health care team)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ON TRAC Transition Clinical Pathway (Complex)
RENAL/DIALYSIS/TRANSPLANT SEPTEMBER, 2015 1/7

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On Trac Transition Clinical Pathway (Simple) Renal/Dialysis/Transplant

ON TRAC TRANSITION CLINICAL PATHWAY (SIMPLE)

RENAL/DIALYSIS/TRANSPLANT
DATE INITIATED ___/___/_____ DATE LAST CLINIC VISIT ___/___/_____
DD MM YYYY DD MM YYYY

Preferred Name_______________________________________________ Transfer Information Checklist

Date of Birth _____________________PHN#_______________________
Initiating Clinic________________________________________________

Practitioner

Specialist
Family
Family
Youth/
These people have been sent the most

Adult
Diagnosis Primary__________________________________________ recent attachments (where applicable):
Secondary __________________________________________________
Youth Email__________________________________________________ Medical Transfer Summary
Youth Cell # _________________________________________________ Adult Clinic/ Office Information
Relevant recent Lab Reports and Flow
Mailing Address_______________________________________________ sheets
Urinalysis, ACR or proteinuria
Contacts Radiology Reports (Eg. nGFR, Renal
Preferred Contact _____________________________________________ U/S)
Phone ______________________________________________________ Biopsy Reports (if available)
ECHOs, ECG
Emergency Contact (if different) _________________________________
All relevant Consult Letters
Phone ______________________________________________________
Psychology Assessment
Education Social Work Assessment
Post-Secondary Plans School_____ Work _____ Other_____ Nutritional Reports
College/University ____________________________________________ C&W Authorization for Release of
Information Consent Form
Location/City ________________________________________________

Special Considerations Consents

Need Interpreter Yes__ Language________________________________ I agree to be contacted about my transition experience up to five years
First Nations Status Yes  No  after leaving BC Children’s Hospital
Youth Signature ___________________ Date _________________________
Financial/Medication Assistance Yes  No 
Contact_____________________________________________________
MSP Fair Pharmacare Non-Insured Health Benefits (NIHB)
Extended Health Benefits_______________________________________

Adult Health Care Team & Recommendations

Family Practitioner _________________________________ Phone ____________________ Frequency of visits _________________________
Address _______________________________________________________________________________________________________________
Adult Specialist _________________________________ Phone _____________________ Date of First Visit __________________________
Address _____________________________________________________________________ Frequency of visits __________________________
Purpose _______________________________________________________________________________________________________________
Recommended Tests (How often?) _______________________________________________________________________________________
Youth’s strengths and concerns on transfer (to be completed by youth, parent/family and/or health care team)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
ON TRAC Transition Clinical Pathway (Simple)
RENAL/DIALYSIS/TRANSPLANT SEPTEMBER, 2015 1/4

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Renal/Dialysis/Transplant – Medical Transfer Summary

RENAL/ DIALYSIS - Medical Transfer Summary Transcription Code #102

Patient Identification Using BC Transcription Services Please send copies to

Dial 1-855-666-3240 or x4799 (internal)  Family Physician
Enter Encounter # to populate: First and Last Names
Then enter: Phone______________________________
Patient Name Unique ID (MSP# or assigned) + # key Fax________________________________
Provincial Health Number Facility Code 58 + # key (BC Children’s)  All Adult Specialist(s) List all known
Medical Record Number Work Type 102 + # (Medical Transfer Summary) First and Last Names
Patient location of visit Patient 7 digit visit # + # key Specialty
Date of birth Phone______________________________
Gender Voice prompt – verify Patient Name Fax________________________________
Date of Service/ Discharge  Patient – Copy to ehealth viewer
Press 2 to begin Dictation using MTS outline First and Last Names
below  Author
End with “Please send copies of report to…” First and Last Names
Press 5 to end dictation and log off
Topic Content
Transfer of Specialty Care Timing when Specialist(s) will take over care (suggested within 6 months). This document
requests transfer of care. Please send confirmation of acceptance of transfer of care and
date of first appointment. Please send copy of letter after first visit.
Primary Renal Diagnosis and other diagnoses
Condition Specific Information o Date of diagnosis and significant investigations
o Renal Biopsy (if applicable)
o GFR Category (CKD Stage), Level of Albuminuria
o Co-morbidities (Renal and Non-renal)
o Dietary Restrictions or Supplements
o Dialysis Prescription (if applicable)
Preferred Treatment Modality
Major Events Birth History
Date, event, outcome and plan
Medications Name, dose, rationale, plan
Previous medications - Rationale for changing medication protocols
Indications and contraindications for medications
Specific drug interactions and alerts
Results Most recent lab work and imaging with important trends
**Alerts Allergies, clinical warnings, other risks in ongoing care
Red Flag condition specific and unresolved transition related issues
Immunizations Flag any condition-specific immunizations, protocols, alerts and future
requirements
Rationale for non-completion of recommended schedule
**Psychosocial/ Special Psychosocial information pertaining to success of primary/specialist care, eg.)
Considerations cognitive level, communication strategies/barriers, family dynamics and
compliance, finances and travel issues (outside lower mainland)
Need for an interpreter
**Overview/Plan Flag restrictions: activity/ work
Youth strengths/concerns for discharge/transfer
Anticipatory Guidance and Condition-specific and potential complications/ late effects
Recommendations for Future Monitoring of medications and suggested tests and lab work
Care BC Ministry of Health Guidelines: Chronic Kidney Disease: Identification, Evaluation &
Management of Patients ([Link])

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Appendix D: Home Therapies: Patient Assessment

Home Therapies
Patient Assessment
The following assessment questions may be useful as a guide to develop an effective plan of care for
the home therapy patient.

Patient responses will guide the plan of care to:

• Be individualized
• Specify the services necessary to address the patients needs identified in the assessment
• Include measurable and expected outcomes
• Include estimated timetables to achieve outcomes
• Contain outcomes consistent with current evidence base professionally accepted clinical practice
standards

ASSESSMENT COMMENTS CONSIDERATIONS

COGNITIVE ABILITY
EMPLOYMENT
• Full time
• Part time
• Retired
• Unemployed
» Occupation
» Hobbies

LEVEL OF INDEPENDENCE • May require open discussion

• Independent with pts family and/or support
• Needs assistance person to identify their
• In what? commitment level to assist.
• Totally dependent • May consider PD Assist if patient
meets eligibility criteria.

LEVEL OF EDUCATION • May need to consider training

• No education material and methods to
• Elementary match education level. If
• High school illiterate, pictures and return
• College/university demonstrations may be required
for training.

LANGUAGE • May need to consider training

• English material and methods to
• Other match education level. If
• Spoken illiterate, pictures and return
• Written demonstrations may be required
• Read for training.

continued...

BC Provincial Renal Agency • Suite 700-1380 Burrard St. • Vancouver, BC • V6Z 2H3 • 604.875.7340 • [Link] November 2017

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Home Therapies Patient Assessment

ASSESSMENT COMMENTS CONSIDERATIONS

BARRIERS TO THE PATIENT’S • May require open discussion
ABILITY TO COMMUNICATE with family and/or support
VERBALLY IN ENGLISH person to identify their ability to
• Not able to communicate in assist for training and ongoing
English communication between patient
and program.
• Only able to communicate
basic needs to staff (uses
single words or short phrases
– requires interpretation
assistance for conversations
and care planning)
• Able to communicate with
staff in most situations (able
to carry on conversations with
staff. Requires occasional
interpretation assistance for
more complex conversations)
PAST EXPERIENCES WITH Questions to consider:
LEARNING NEW SKILLS • Have they learned to use a
• No computer?
• Yes
• Do they use automated banking?
• How did they learn these skills?
• Consider using VARK
questionnaire to assist in
identifying learning styles:
http:/[Link]
PATIENT’S LEARNING • Develop a teaching plan that
PREFERENCE? mirrors the patient’s learning
• Visual preference.
• Hearing
• Doing
• Solitary (use self study)
• Social (group activity, role
playing

KNOWN OR DIAGNOSED • May require an open discussion

COGNITIVE DEFICITS with family and/or support
REPORTED BY PATIENT OR person to identify their
FAMILY? commitment level to assist if
• No cognitive.
• Yes • Impairment inhibits short term
memory and ability to learn and
or make decisions related to
treatment.
• May require SW consult and
assistance to perform clock test
and/or mini mental health test.

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Home Therapies Patient Assessment

ASSESSMENT COMMENTS CONSIDERATIONS

DOES PATIENT REPORT ANY • Assess if patient’s ability to
PAST OR CURRENT MENTAL self manage at home may
HEALTH ISSUES, CONCERNS be affected. Active chemical
OR MOOD DISTURBANCES dependency may impair the pts
(FEELING OF DEPRESSION OR ability to assess health need.
ANXIETY)?
• Dementia Questions to consider:
• Anxiety disorder • Is patient followed with psych/
• Depression social work support?
• Alcohol or substance • Is a consult required?
abuse
• Post-traumatic stress
syndrome
• Alzheimer’s
• Bipolar disorder
• Schizophrenia
• Other

HOME ENVIRONMENT AND LIVING ARRANGEMENTS

LIVING ARRANGEMENTS Questions to consider:
• Lives Alone • Will patient need support to self
• With partner/spouse manage?
• With children
• Extended family • Do they have someone to assist?
• Roommate • Does the patient identify that
help will come from someone
that they live with?

TYPE OF DWELLING • Can home therapy be

• House ☐ Rent ☐ Own performed in their current living
# of levels environment?
• Apartment ☐ Rent ☐ Own • Electrical and plumbing
• Assisted living/LTC/ upgrades may be required
nursing home for HHD. If renting, landlord
• No fixed address approval may be required.
• PD is not accommodated in all
LTC facilities.
PETS SHARING LIVING SPACE? • Is the patient aware that pets
• No cannot be in the room when they
• Yes are setting up for dialysis?
Type:

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Home Therapies Patient Assessment

ASSESSMENT COMMENTS CONSIDERATIONS

STORAGE SPACE FOR HOME • Is there adequate home storage
PRODUCTS? for supplies and equipment?
• No May need to consider:
• Yes • Altering supply delivery
Location: schedules (increase frequency
• Heated and reduce quantities)
• Well lit • Storing some supplies in an
• Well ventilated alternative location and move as
required.
DESIGNATED AREA FOR
PERFORMING DIALYSIS?
• No
• Yes
Where:

HAS ACCESS TO ELECTRICITY, • Electrical and plumbing

WATER AND DRAIN FOR upgrades may be required for
AUTOMATED EQUIPMENT? HHD.
• No • If renting, landlord approval may
• Yes be required.

DOES THE PATIENT HAVE

A TELEPHONE LINE OR
FUNCTIONING CELL PHONE?
• No
• Yes

IS THERE ROAD ACCESS FOR

SUPPLY DELIVERIES AND/
OR PD ASSIST SERVICES (IF
REQUIRED)?
• No
• Yes

IS THE PATIENTS CURRENT • Is a home visit required to assess

LIVING SITUATION A home environment?
POTENTIAL BARRIER TO
POSITIVE TREATMENT
OUTCOMES?
• No
• Yes

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Home Therapies Patient Assessment

ASSESSMENT COMMENTS CONSIDERATIONS

PHYSICAL ABILITY
PERTINENT MEDICAL HISTORY

PREVIOUS ABDOMINAL
SURGERIES
• No
• Yes
Type:

PATIENT HAS NORMAL VISION May need to consider using specific

WITH OR WITHOUT EYE patient education tools:
GLASSES • Large print/font
• No • Audio tools
• Yes

WHAT VISION AIDS DOES THE

PATIENT USE?
• Wears glasses
• Contact lenses
• Magnifier
DOES THE PATIENT HAVE • May need to consider:
HEARING PROBLEMS? • print material
• No • demonstrations
• Yes • diagrams
• pictures
• Consider contacting Canadian
Hard of Hearing Association.

DOES THE PATIENT USE

HEARING AIDS?
• No
• Yes L R

DOES THE PATIENT HAVE • OT support may be required to

WEAKNESS OR TREMORS IN assist with support aids/options.
UPPER LIMBS? • Open discussion required to
• No identify available support in the
• Yes L R home and the commitment level
of the support.
• PD Assist may be an option if
patient meets eligibility criteria.

WEAKNESS IN LOWER LIMBS

• No
• Yes L R

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Home Therapies Patient Assessment

ASSESSMENT COMMENTS CONSIDERATIONS

AMPUTATION IN UPPER LIMBS • OT support may be required to assist with support
• No aids/options.
• Yes L R
DOES THE PATIENT REQUIRE • May assist in assessing the patient’s ability to
FURTHER FUNCTIONAL perform specific tasks physical, cognitively, or
ASSESSMENT? reading skills
• No
• Yes- If so, refer to
Functional Assessment
for PD or HHD.

ASSESSMENT OF CAREGIVER (IF APPLICABLE)

CARE GIVERS RELATIONSHIP
TO THE PATIENT
• Spouse/partner
• Friend
• Other family member

CARE GIVER LIVES WITH THE

PATIENT?
• No
• Yes
CARE GIVER UNDERSTANDS
COMMITMENT INVOLVED
• No
• Yes
CARE GIVER IS WILLING AND
MOTIVATED
• No
• Yes
CARE GIVER HAS NO BARRIER
IN COGNITIVE ABILITY
• No
• Yes
CARE GIVER IS AVAILABLE AT
THE NECESSARY TIMES FOR
DIALYSIS
• No
• Yes

IS THERE ACCESS TO THE • A requirement for safe delivery of supplies.

MAIN ROAD FOR DELIVERIES? • If no access to main road, have the patient
• No describe how deliveries will be made to the
• Yes home. Will require further evaluation by team.

DOES THE PATIENT HAVE • Mandatory for emergencies and machine issues.
A TELEPHONE LINE OR
FUNCTIONING CELL PHONE?
• No
• Yes

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Peritoneal Dialysis
Functional Assessment

The functional assessment provides examples of basic skills that are needed
to be able to perform and manage Peritonal Dialysis.

Instructions to perform the functional assessment:

1. Gather supplies and place them on a working surface.

2. Nurse to demonstrate and verbally describe basic skill (#1-8) as it is performed.
3. Have patient perform each basic skill (#1-8) following.
4. Patient to complete basic skill #9 and #10 without assistance.
5. Nurse to document observations.

Supplies required

• Transfer set with white mini cap

• Mini cap
• Red clamp
• Mask
• PD solution bag with tubing and colored pull ring attached
• 2 liter PD solution bag
• Tongue depressor
• IV pole
• Pencil/pen

Resources

VIHA: Functional assessment. 22 June 2016 Reviewed by: Backx,T, VKCC, NKCC, CI/SI Navigators

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Peritoneal Dialysis Functional Assessment

CAN CANNOT
BASIC SKILL PERFORM PERFORM COMMENTS

1. Pick up the PD solution bag and hold it

over head for a count of 3.

2. Hang PD solution bag on IV pole.

3. Hold the transfer set and twist the clamp

open and closed until it clicks.

4. Open a minicap package and place

on the end of the transfer set without
contamination.
5. Remove the mini cap from the transfer set.

6. Remove the colored ring from the PD

solution bag.

7. Attach the red clamp anywhere along the

PD tubing and snap it closed. Release the
clamp to open.
8. Pick up the tongue depressor and snap it
into 2 pieces.
9. Look at the picture of the home choice
cycler below and record what is seen in
the display screen.

What is displayed on the screen?

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Peritoneal Dialysis Functional Assessment

Clock Test

CAN CANNOT
BASIC SKILL PERFORM PERFORM COMMENTS

10. Using the circle diagram below as a clock

face:
1. Put the numbers on the face of the
clock.
2. Make the clock say “10 minutes after 11”.

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Peritoneal Dialysis Functional Assessment

PD Functional Assessment-
For Nursing Use Only

Patient name Attach patient label here

Assessment date

Assessment completed by

Patient completed all aspects of the assessment following visual/verbal demonstration without
difficulty.
☐ Yes ☐ No
Comments:

Patient required repeated prompting to complete all aspects of the assessment following visual/
verbal instructions.
☐ Yes ☐ No
Comments:

Clock test score:

• Score 1 point for each number in its correct eighth (1,2,4,5,7,8,10,11).

• No points for pen marks or words instead of numbers.
• Score 1 point for short hand pointing to number 11
• Score 1 point for long hand pointing to number 2
• No points for hands approximately the same length
• No point if the short hand is pointing to the 2 and the long hand pointing to the 11

Results:
10 or greater suggests cognitive impairment unlikely
6 - 9 indicates probable impairment
0 - 5 indicates prominent impairment

Comments:

Future Steps:

Documentation completed: ☐ Chart ☐ PROMIS

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Appendix E: PD Assist Eligibility Criteria

PD client and or support:

• has completed the PD training
• can perform the procedures related to connecting and disconnecting from the cycler and associated
troubleshooting of cycler complications that may occur during the therapy.
• can manage all non-cycler aspects of their PD care inclusive of but not limited to fluid management, access
care, effluent assessment, supply ordering.
• can contact the PD program to communicate any identified concerns or problems associated with their health
status or PD therapy.
• are unable to perform the cycler set up and dismantling procedure due to physical, cognitive, psychological
and or social reasons.

Assistance may be required in one of the following scenarios:

Long term:
Assistance by a CG is required one time per day, several times each week or up to 7 days per week until the
client* leaves the PD program.

²² Health status prevents the client from dismantling/setting up the cycler.

²² Dexterity/strength/vision deficits limit the ability of the client to complete the tasks
associated with cycler dismantling/set up. Examples of deficits include but are not
limited to the inability:
PHYSICAL
• to gather supplies
• lift dialysate solution bags
• open supply packaging
• break seals on solution bags

²² Cognitive function deficits (memory, problem solving, decision making) which may/
will impact the client’s ability to safely complete the necessary steps associated with
cycler dismantle/set up. Examples may include but are not limited to the inability to:
• Correctly sequence tasks associated with cycler set up/dismantle
COGNITIVE
• Troubleshoot potential cycler machine alarm conditions occurring during cycler
PSYCHOLOGICAL
set up/dismantle
²² Learning deficits which impact the client’s ability to safely complete the steps in-
volved in cycler set up/dismantle
²² Confidence to perform cycler set up/dismantle procedures independently is absent

²² Absent or intermittent availability of support person(s) following identification that

SOCIAL
such support to manage CCPD is needed

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Short term including respite:

Assistance required by a Caregiver for 2 weeks to 3 months for what is thought to be temporary reasons. The
client is anticipated to be able to return to total self-management of PD cycler therapy however may require long
term assistance if status remains compromised.

²² Health status which is assessed to temporarily prevent the client from having the
ability to set up/dismantle the cycler. Example: cardiovascular changes, recent hospi-
talization, surgery,
²² Dexterity/strength/vision deficits felt to be temporary, which limits the ability of the
client to complete the tasks associated with cycler set up/dismantle. Examples of
PHYSICAL
deficits include but are not limited to the inability to:
• gather supplies
• lift dialysate solution bags
• open supply packaging
• break seals on solution bags

²² Cognitive function (memory, problem solving, decision making) felt to be temporary

and is assessed to impact the client’s ability to safely complete the necessary steps
associated with cycler set up/dismantle. Examples may include but are not limited to
the inability to:
• Correctly sequence the steps associated with cycler set up/dismantle
COGNITIVE
• Troubleshoot potential cycler machine alarm conditions occurring during cycler
PSYCHOLOGICAL
set up/dismantle
²² Learning deficits which impact the client’s ability to safely complete the steps in-
volved in cycle that could improve with exposure to using the cycler.
²² Lack of confidence to perform cycler set up/dismantle procedures independently, but
could improve with exposure to using cycler

SOCIAL ²² Support person, who provides assistance for CCPD, is intermittently unavailable

* The term client refers to either the PD client or their designated support person if required.

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Appendix F: Provincial Guideline: Indications & Urgency Criteria for Surgical Peritoneal
Dialysis

General Surgery
BC Surgical
Scheduled vs. Wait
Priority
Unscheduled Time Description Details
Level
Target
(see note 4)

Unscheduled Not identified <24 hours Immediate need for Inpt

surgical intervention • Symptomatic renal failure
Insertion of PD catheter • Failing vascular (HD) access,
• Urgent new dialysis start within 48 hr.
and not a candidate for bedside or
radiological insertion,
• Non-functioning PD catheter for PD
patient
• Failed bedside or radiological PD cath

Immediate need for Inpt

surgical • acute peritonitis,
intervention • tunnel infection
Removal of PD catheter

Scheduled 1 2 weeks General Surgery Other P1 Outpatient

Insertion of PD catheter • Symptomatic renal failure with dialysis
initiation within 2 weeks
• Failing HD access
• Urgent change in status
Removal of PD catheter • Nonfunctioning PD catheter for current
PD patient

Outpatient
• Recurrent peritonitis
• Tunnel infection
• Sclerosing peritonitis
• Fungal peritonitis

Scheduled 2 4 weeks General Surgery Other P2 Outpatient

Insertion of PD catheter • Asymptomatic advanced renal failure with
dialysis initiation within 6 weeks
Repair of hernia
Removal of PD catheter

Transferred to HD- noninfectious reasons

Scheduled 3 6 weeks General Surgery Other P3 Asymptomatic advanced renal

Insertion of PD catheter failure with estimated peritoneal dialysis start
time less than 8 weeks
Removal of PD catheter

Post-transplant
Transfer to HD
continued...

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BC Surgical
Scheduled vs. Wait
Priority
Unscheduled Time Description Details
Level
Target
(see note 4)

Scheduled 4 12 weeks General Surgery Other P4 Asymptomatic advanced renal

Insertion of PD catheter failure with estimated peritoneal dialysis start
tie less than 3 months
Scheduled 5 26 weeks General Surgery Other P5 Advanced renal failure with
estimated peritoneal dialysis start date less
than 6 months

Vascular Surgery
BC Surgical
Wait
Scheduled vs. Priority
Time Description Details
Unscheduled Level
Target
(see note 4)

Scheduled 1 2 weeks CRF- poor dialysis Outpatient

access OR failing dialysis • Symptomatic renal failure with dialysis
access (dialysis already initiation within 2 weeks
underway) • Failing HD access
• Urgent change in status
• Nonfunctioning PD catheter for current
PD patient

Outpatient
• Recurrent peritonitis
• Tunnel infection
• Sclerosing peritonitis
• Fungal peritonitis

Scheduled 2 4 weeks CRF – dialysis already Outpatient

started by catheter • Asymptomatic advanced renal failure with
dialysis initiation within 6 weeks

Repair of hernia

Transferred to HD- noninfectious

Scheduled 3 4 weeks CRF - dialysis anticipated Outpatient

within 3 months Asymptomatic advanced renal failure

Scheduled 4 6 weeks CRF – dialysis Outpatient

anticipated Asymptomatic advanced renal failure
within 3-6 months

Removal of insertion Post-transplant

Scheduled 5 26 weeks CRF – dialysis Advanced renal failure
anticipated in more than
6months

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Notes:

1. Sched = scheduled; Unsched = unscheduled. CRF = Chronic Renal Failure

2. Refer to attachment #1 for a surgical HD procedure (AV fistula or AV graft).
3. Wait time targets for scheduled surgeries are the same as on the Vascular Surgery Provincial List of Patient
Condition and Diagnosis Descriptions (V6 - 2015; Surgical Patient Registry). The latter does not identify
wait times for unscheduled surgeries, so the ones above were developed by a Provincial Renal/VA Surgery
Working Group and are specific to renal VA access procedures.
4. Wait Time Targets:
• Adults = time from booking form received in OR to procedure date.
• Children = time from decision to have surgery to procedure date.
5. BC Surgical Priority Levels:

Priority Level Wait Time Target (Wks)

1 2

2 4

3 5

4 12

5 26

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Appendix G: BCPRA Funding Model

PD Program Entry -Table 1

Ongoing PD follow-up Table 2

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Table 3- Acuity Level

LEVEL HEMODYNAMICS ADL ACCESS TREATMENT NURSING INTERVENTIONS TEACHING
1 HYPOTENSION Not Present TYPE AVF or Graft MEDICATION None or EPO only TIME ELEMENT 10-15 Mins TEACHING Completed

HYPERTENSION Not Present COMPLICATIONS No DRESSINGS None ISOLATION No isolation PHYSICAL Non-Existent
Independent Complications BARRIERS TO
(might use SELF DIALYSIS
ANGINA Not Present walking aides, PRU Greater than 70 OTHER None SWABS/BLOOD Routine EMOTIONAL Non-Existent
w/c etc. without STUDIES BARRIERS TO
assistance) SELF DIALYSIS
DIFFICULTY Not Present VITAL SIGNS Hourly COGNITIVE Non-Existent
REMOVING FLUID BARRIERS TO
SELF DIALYSIS
O2 THERAPY No O2 Therapy SELF CARE Mastered Skills
SUFFICIENCY

2 HYPOTENSION Occasional TYPE Permcath MEDICATIONS IV iron TIME ELEMENT 15-30 Mins TEACHING Newly Taught/
OR Temporary Occasional
Line OR Dual Review
Access
HYPERTENSION Occasional COMPLICATIONS L1: No DRESSINGS Small ISOLATION Alert PHYSICAL L1: Non-
L1: Independent Complications (Equipment BARRIERS TO Existent
(might use Disinfections) SELF DIALYSIS
walking aides,
ANGINA Occasional w/c etc. without PRU 65-70 OTHER L1: None SWABS/BLOOD Bi-weekly EMOTIONAL L1: Non-
assistance) STUDIES BARRIERS TO Existent
SELF DIALYSIS
DIFFICULTY L1: Not present VITAL SIGNS L1: Hourly COGNITIVE L1: Non-
REMOVING FLUID BARRIERS TO Existent
SELF DIALYSIS
O2 THERAPY L1: Not present SELF CARE Self Care with
SUFFICIENCY Assistance

3 HYPOTENSION Weekly TYPE Any access MEDICATIONS IV antibiotics, TPA TIME ELEMENT 30-45 Mins TEACHING Teaching in
type instilled post Progress/
Ongoing
Review
HYPERTENSION Weekly COMPLICATIONS Occasional DRESSINGS Post op Minor ISOLATION Confirmed PHYSICAL Minor
Complications Positive (Spatial BARRIERS TO
Minimal Isolation/ SELF DIALYSIS
assistance (to Curtain)
bear weight,
ANGINA Occasional weigh, transfer PRU 60-65 OTHER L1: None SWABS/BLOOD Weekly EMOTIONAL Minor
to bed/chair) STUDIES BARRIERS TO
SELF DIALYSIS
DIFFICULTY Occasional VITAL SIGNS Every 30 mins COGNITIVE Minor
REMOVING BARRIERS TO
SELF DIALYSIS
O2 THERAPY Occasional SELF CARE Limited Self
SUFFICIENCY Care

4 HYPOTENSION Each Run TYPE Any access MEDICATION TPA pulsed, infusion, TIME ELEMENT 45-60 Min TEACHING Teaching
Type IDPN Started/Initial
Instructions
HYPERTENSION Each Run COMPLICATIONS Weekly DRESSINGS Post-op Major ISOLATION L3: Confirmed PHYSICAL Moderate
complications Positive (Spatial BARRIERS TO
One person Isolation / SELF DIALYSIS
assist to transfer Curtain)
/ transfers via
ANGINA Weekly bed/chair PRU 55-60 OTHER Healed Trach Care/ SWABS/BLOOD Each Run EMOTIONAL Moderate
Blood Products/Ostomy STUDIES BARRIERS TO
Care SELF DIALYSIS
DIFFICULTY Weekly VITAL SIGNS L3: Every COGNITIVE Moderate
REMOVING FLUID 30 Min BARRIERS TO
SELF DIALYSIS
O2 THERAPY Weekly SELF CARE L3:Limited Self
SUFFICIENCY Care

5 HYPOTENSION Each Run, TYPE Any access type MEDICATIONS S/L antihypertensives / TIME ELEMENT 60-90 Min TEACHING Untrained
resistant to IV mannitol / IV ACDA Chronic Patient
Current Therapy
HYPERTENSION Each Run, COMPLICATIONS Complications DRESSINGS Major, infected draining ISOLATION Isolation Room PHYSICAL Serious
resistant to Each Run wound BARRIERS TO
Current Therapy SELF DIALYSIS
ANGINA Each Run Two person PRU 50-55 OTHER Plasma Exchange SWABS/BLOOD Multiple Per Run EMOTIONAL Serious
major assist to STUDIES BARRIERS TO
transfer SELF DIALYSIS
DIFFICULTY Each Run VITAL SIGNS Every 15 Min COGNITIVE Serious
REMOVING FLUID BARRIERS TO
SELF DIALYSIS
O2 THERAPY Each Run SELF CARE L3:Limited Self
SUFFICIENCY Care

6 HYPOTENSION L5: Each Run, TYPE Any access type MEDICATIONS Inotropes TIME ELEMENT 1-1 Nursing TEACHING Untrainable
Resistant to Patient
Current Therapy
HYPERTENSION L5: Each Run, COMPLICATIONS Major, Ongoing DRESSINGS L5: Major, infected ISOLATION Positive PHYSICAL Extreme
Resistant to Complications draining wound Pressure BARRIERS TO
Current Therapy Completely Isolation SELF DIALYSIS
dependent (use
ANGINA Uncontrollable of mechanical PRU Less than 50 OTHER Suction/Airway SWABS/BLOOD L5: Multiple EMOTIONAL Extreme
lifts ) Management STUDIES per Run BARRIERS TO
SELF DIALYSIS
DIFFICULTY Unable to VITAL SIGNS Constant COGNITIVE Extreme
REMOVING Remove Fluid Monitoring/ BARRIERS TO
Cardiac SELF DIALYSIS
O2 THERAPY O2 Dependant Monitoring SELF CARE Full Care
SUFFICIENCY Required

LEVEL I II III IV V VI
POINTS 6 7-12 13-18 19-24 25-30 31-36

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